Medical Weight Management

This paper was submitted as part of Dr. Mason's application for ACOFP Fellowship, which recognizes exceptional national, state, and local service through teaching, authorship, research, or professional leadership. Visit the ACOFP Fellows page to learn more about fellowship and the nomination process.

ABSTRACT 

Weight management is becoming a more prevalent concern among individuals seeking care from their family medicine physician. The overall prevalence of this disease state has been increasing in recent years, and continues to do so.   A multi-disciplinary approach to treatment seems to have the greatest potential at producing long-term effects on weight.  By treating this disease, it has been demonstrated to have improvements in diabetic control, lipid control, hypertension, cardiovascular risk factors, obstructive sleep apnea, and non-alcoholic fatty liver disease.  The number of medications approved and in use for obesity has also significantly increased in recent years.  Each of these medications comes with their own risks and benefits,  and each has a different average amount of percentage of body weight loss (highest being seen in tirzepatide and semaglutide), along with changes in high density lipoproteins (HDL), low density lipoproteins(LDL),  triglycerides (TG),  systolic blood pressure, and diastolic blood pressure.  How this care is delivered also has added benefits and challenges.  Telehealth usage has significantly increased in recent years, and is now being adapted to the treatment of obesity with the added benefit of improving access while decreasing costs.  Telehealth has limitations in the form of increased need for technology that not all individuals may have.  Many concerns about treating this disease surround the economic value of obesity treatment.  It has been demonstrated that over time, the costs associated with treating obese individuals decrease with significant weight loss and the prevalence of obesity related disease states also decrease as well.      

BACKGROUND

It has been well established that obesity in the United States is a chronic and very serious disease with approximately 40% of the adult population and 10% of the pediatric population having been diagnosed at this time.  Medical intervention for these individuals begins with lifestyle modifications, including caloric restriction and increased energy consumption through amplified activity, generally assumed to be a minimum of 150 minutes of moderate intensity level activity per week on average.  The homeostatic functions of the body, including neuroendocrine function, neuronal signaling, and changes to the adipose-to-skeletal muscle ratios, make it difficult to maintain long term weight loss as the body attempts “hypometabolism and hyperphagia” to combat the reduction in usable energy, resulting in 70% of individuals that lost weight regaining at least half of the weight loss at 2 years and a return to baseline within 3-5 years (1,2).  The highest success rate for long-term significant weight loss, non-surgically, is through diet, consistent with low carbohydrate and low-fat consumption, for 6 months, followed by pharmacotherapy for at least 12 months (3).  Multi-disciplinary obesity management treatment centers are now becoming the standard for care of patients with obesity and provide medical specialists for the initial assessments and medical management while following evidence-based guidelines for long-term treatment of this disease, leading to significant improved quality outcomes, patient-centered care, consistent patient messaging and reduction in overall treatment costs (4,5).  The use of behavioral therapy, including teaching individuals how to act around food triggers, and cognitive therapy, including teaching how to alter thoughts about food, can also help guide patients to build realistic goals for long-term success with meaningful weight loss (5).  Family Medicine is well equipped to be able to provide this comprehensive and inclusive care to their patients; for this care to be effective at least 12 contacts, either in the office or telehealth, must be completed (6).  Common themes in treating obesity within primary care include: the belief that treating obesity is essential to primary care, because of the challenges that treating this disease poses many providers opt out, and those that choose not to opt out find this work to be “feasible, satisfying and worthwhile” (7).  There is not a correlation between patient socio-economic status and weight related behaviors, but the availability of restaurants showed that individuals were more likely to undergo some weight control behaviors individually about activity level and eating habits as the number of restaurants increased (8).  Nutrient selection behaviors demonstrate a positive correlation with obesity and the percentage of obese individuals exceeding the recommended consumption of fat, 85%, and sodium, 92%, and less than half of these individuals consumed the recommended number of fruits, vegetables, dairy, and grains (9). 

BEHAVIORAL INTERVENTIONS

Intensive, multicomponent behavioral interventions have demonstrated a significant ability to improve weight status in adult patients, with the greatest differences seen in those with elevated glucose levels, with minimum to no adverse reactions.  Intensive behavioral therapy should focus on four main areas: goal setting (making goals to assist in loss of 0.5-1 kg on average per week), self-monitoring (allowing for instant feedback about the effectiveness of patient driven/chosen interventions), stimulus control (altering stimuli perception and the patients behavioral response) and problem solving (10).  How that intervention is delivered, either by group, individual, technology-based or a mixture, had no significant effect on health related quality of life but all modalities increased likelihood of meaningful weight loss by almost double the standard care of diabetes at 12-18 months,  and a reduction in diabetes incidence between the 3-9 year marks (11).  These intensive lifestyle interventions also resulted in a decrease in all-cause mortality, with the greatest benefit being seen in those individuals that had lost over 10% of their body weight (11).  While undergoing the intensive behavioral components of weight management, there were no significant differences in depressive symptoms, antidepressant medication use, or mental component scores and were not correlated with amount of weight loss (12).  These intensive behavioral interventions do require a significant number of resources, namely time on behalf of the physician and patient, in order to succeed.    

PHARMACOTHERAPY

The treatment for the obese patient is multifactorial, including behavioral, pharmacological, medical, and psychological; one-size-fits-all management of these individuals is often something that will not successfully lead to long-term weight loss and weight loss maintenance.  In Table 1, each pharmacological intervention has varying degrees of average percentage of weight loss associated both in the short-term and long-term use (13).  In Table 2, it can be seen that each pharmacological intervention also has varying degrees of change associated with other cardiovascular risk factors, such as systolic/diastolic blood pressure and the lipid panel measurements, and this information can be used to help facilitate medication choices (13).  When predicting which individuals will have the greatest initial weight loss, those with higher body mass index (BMI) or use of anti-obesity medications were found to have the greatest success (14). When predicting which individuals will have the best chance of maintaining their weight-loss long-term there was no statistically significant finding, though older age, and use of anti-obesity medications (AOM’s) were the closest to approach significance (14).  The importance of current medication review to identify how current medical therapy that may be contributing to obese state is paramount to improving the success of the individual patient.  In Table 3, commonly prescribed medications for different disease states are put into 2 categories, those that are likely to cause weight gain and those that are either weight neutral or can cause weight loss (15).  Using this information allows family medicine physicians to evaluate how an individual patient is currently being treated and alter their treatments to allow for significant weight loss.    

TELEHEALTH IN OBESITY TREATMENT

Telehealth treatment for obesity has the potential benefits for allowing for improved access to care to rural and underserved areas,  and an associated reduction in patient costs in time and currency, improved cost effectiveness through improved integration of team based care and specialized care groups (i.e. nutritionist, exercise therapist, behavioralist, etc.), improved retention rates in weight management programs, seen as 96% vs 70% for those enrolled with in-person only programs and reduction in weight stigma (16,17)  It also has potential limitations in the need for technologic abilities and equipment, less accurate vital sign measurements including weight, BMI, and waist circumference, and a limited ability to perform a through physical examination (16,17).  Telehealth treatment of obesity demonstrated a decrease in fasting blood glucose (-4.26 mmol/L) 2-hour post-prandial glucose (-4.48 mmol/L), and glycated hemoglobin (-4.17 %) that was more pronounced when compared to conventional in-person treatment (18).  For providers, using telehealth allows for the use of the same or even less visit time needed in many visits and all providers found they were either somewhat or very satisfied with the interpersonal connections made during these telehealth visits (19).  These types of visits also had an associated improved satisfactions scores for those patients who must travel more than 30 minutes for in-person visits (19).  When developing an online weight-management intervention program, it is important to note that the degree of participation influences the amount of body weight loss and the likelihood of achieving 5% weight loss, as demonstrated in Table 4 (20). 

CARDIOVASCULAR BENEFITS TO TREATING OBESITY

Lifestyle modifications in an attempt to lose weight demonstrated an ability to promote a healthier overall lifestyle and corresponding improvement in heart rate recovery following exercise, indicating an overall improvement in fitness levels (21).  In individuals undergoing intensive lifestyle modifications, fitness levels increased by 20.9% on average (compared to less intensive measurements of 5.8%) and there was also a corresponding reduction in the prevalence of the need for diabetes, hypertension and lipid lowering medications (22).  Weight cycling, or increasing weight variability over time, is associated with significant increased risk of major adverse cardiovascular events, MACE, throughout the patient’s lifecycle, presumably due to the inflammatory reaction of the body during weight gain (23).  Pharmacotherapy has been shown to benefit cardiovascular risk with the use of phentermine (reduction in blood pressure), phentermine/topiramate (reduction in Framingham Risk Model of 0.3-0.5%), bupropion/naltrexone (decrease heart rate), liraglutide (decreased blood pressure, total cholesterol, triglycerides, A1c, fasting glucose, and fasting insulin levels along with decreased deaths due to cardiovascular causes and decreased nonfatal myocardial infarction and nonfatal stroke) (24).  Historically the use of phentermine in patients with cardiovascular risk was advised to be done with caution, but newer data demonstrates that this medication can be used long-term, and will also reduce the risk of cardiovascular events rather than the previous thought of increasing them.    

OTHER MEDICAL CONDITION BENEFITS TO TREATING OBESITY

Non-alcoholic fatty liver disease (NAFLD) is a disease state with climbing incidence in the United States with the possibility of advancing to advanced liver disease.  The common thought is that by treating the underlying disease state, generally obesity, this condition could reverse and possibly go into full remission.  NAFLD benefits from a modest amount of weight loss and demonstrated a decrease in ALT by 11 and AST by 7, along with a decrease in the median liver transient elastography by 1.3 kPa in those undergoing this weight loss,  resulting in a 10-year cardiovascular risk reduction of 5% (25).  In those individuals showing a weight loss, the lifetime quality-adjustment life years (QALYs) were 11 years in the clinical group (compared to 10.9 years in the reference group) resulting in a difference of approximately 29 days (25).  The hope is that with significant sustained weight loss the reduction in incidence of non-alcoholic steatohepatitis and possible cirrhosis, but no studies were found identifying this reduction statistically.    

Obstructive sleep apnea (OSA) can also be improved with meaningful weight loss.  When involved in an intensive lifestyle intervention, patients showed that they were more than 3 times more likely to have complete resolution of their OSA and that the continued prevalence (when compared to less intensive treatment) was nearly half (26).  There was also a significant difference found in the apnea-hypopnea index among these two groups and that the amount of weight loss, baseline AHI, and interventions independent of weight change were found to be the biggest drivers of the change (27).  Complete remission of OSA at 10 years was 34.4% in the intensive group and 22.2% in the less intensive group (27).  With this increased risk of cardiovascular events in those diagnosed with OSA, a meaningful decrease in weight allows for an associated decreased risk of MACEs.    

ECONOMIC VALUE

As adult obesity cost per patient continues to rise, the value of treating this disease state has the potential for improved economic value.  Studies have demonstrated that the higher the reduction in BMI and the presence of diabetes at onset of weight loss, the higher the medical cost savings with an aggressive weight loss program (28).  In a large program designed for an employer-offered benefit with management of intensive lifestyle intervention, it was found that the return on investment was 2.3:1 for program participants.  Those that completed the program had a larger mean weight loss and cost savings (29).  Most of the cost savings happen longitudinally, with an increase in cost during year one of the treatment group but by the second year these costs plateau, while the untreated individuals continue to show a climb in medical costs (30).  All causes of healthcare costs show a significant decrease in all weight loss groups over time from baseline with the larger savings observed in those with larger percentage of body weight loss (31). 

SUMMARY

Obesity has now reached epidemic proportion in the United States and current trends only look to increase the prevalence of this disease.  Obesity management is becoming an increasing area of focue for family physicians.  Achieving sustained weight loss imparts morbidity, mortality and economic benefits for our patients.  Newer anti-obesity medications, telehealth, and a team-based approach offer family physicians increased opportunities to positively impact patients’ health and quality of life through obesity management. 

Table 1: Trial Data for Pharmacotherapy of Obesity average Weight Loss

Table 2: Trial Data for Pharmacologic Therapy of Obesity

Table 3 Obesogenic Medications and alternatives (weight neutral or weight loss medications)

TABLE 4: Weight Loss for Online Program based on Participation. 

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